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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209373
Report Date: 10/04/2023
Date Signed: 10/04/2023 01:36:56 PM

Document Has Been Signed on 10/04/2023 01:36 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:KERN VILLAGE ASSISTED LIVING FOR SENIORSFACILITY NUMBER:
157209373
ADMINISTRATOR:PARMELEE, SHERYLFACILITY TYPE:
740
ADDRESS:32 BURLANDO ROADTELEPHONE:
(415) 810-0145
CITY:KERNVILLESTATE: CAZIP CODE:
93238
CAPACITY: 22CENSUS: 2DATE:
10/04/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Licensee Anthony Barbato and Administrator Kala GibsonTIME COMPLETED:
01:45 PM
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On 10/04/23, Licensing Program Analyst (LPA) M. Yang conducted an announced Pre-licensing and
Component III inspection. LPA introduced self, stated the purpose of the visit, and met with Licensee Anthony Barbato and Administrator Kala Gibson.

The facility is 11 resident rooms. Fire clearance was granted for 22 Ambulatory for total of 22 capacity. All two residents were present during this inspection. LPA toured the facility with Licensee and Administrator. Facility temperature is at a comfortable temperature. Common areas were furnished and had adequate seating and lighting available. Fire extinguishers was observed and has a service date of 07/26/23. Medications were kept locked in the office inaccessible to residents. Kitchen was toured and observed to have dishes, plate, and utensils. Refrigerator temperature maintained at 36 degrees F and freezer temperature at -2 degree F. LPA observed a 2-day supply of perishable foods and a 7 day supply of non-perishable foods. Knives were observed to be locked and secured in kitchen drawer. Cleaning supplies and chemicals were observed to be in a locked under kitchen sink. Bedrooms were observed to have required furnishings. Bathrooms are observed with securely fastened grab bars in shower and non-skid mat. Bathrooms were observed to be operational. Hot water measured at degrees F range between 106 to 108.3 degrees F in residents’ bathroom. Outside of facility toured and observe free of debris. LPA observed adequate outdoor seatings available for residents. LPA observed an extra supply of bed linens. Smoke detectors and carbon monoxide detectors were observed to be operational during this inspection. First aid kit was observed and contained all required items. Resident records were reviewed. LPA observed resident Admission Agreements, Physician Reports, and Pre-Appraisal. A sample of staff records were reviewed. Staff records were observed to have a criminal record clearance. Facility phone number 760-376-6733.

Component III was conducted during today's pre-licensing visit. I have found that the applicant has met all pre-licensing requirements. LPA will submit documentation to CAB in Sacramento for final review prior to license being issued.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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